Black infants are 255 percent more likely to die in my native California. They are 303 percent more likely to die in Wisconsin. In our nation’s capitol, where the disparity is greatest, black infants are 456 percent more likely to die than white infants.

One public health nurse, Sandra Tramiel, told me in 2012 of her first heartbreaking case: “I’d never seen a tiny coffin before. I remember how hard it was for the family to pull together.”

Tramiel has since retired, but the Alameda County Public Health Department she worked for has done more than mourn with mothers. It pushed a boulder uphill and reduced its black infant mortality rate to 7.6 deaths per 1,000 live births from 2009 to 2011. It had stood at 12.0 as recently as 2005 to 2007.

Have those gains, measured in three-year rolling averages, been sustained? And how did this county do it?

The program names in Alameda are ones you might find in other counties: The federal Healthy Start program established in the 1990s led to the county’s Improving Pregnancy Outcomes Program, or IPOP. The Black Infant Health, or BIH program, receives both federal and state funding.

But beyond the acronyms, the county used epidemiological research to target nine county zip codes, largely in Oakland, where black women were most at risk of losing their baby before the age of 1.

At the Eastmont Town Center, a bankrupt shopping mall that the county gradually converted to a warehouse of public services offices, it held “Club Mom” baby showers where prizes such as diapers and strollers were raffled off. The showers channeled dozens of women at a time to the county’s maternal health services and taught them child-bearing basics such as “kick counts.”

The county also gave grocery store gift cards worth $125 a month to “peer health leaders” who could find and document contact with 20 additional women and help get them under the county’s maternal health umbrella. The health leaders, many of them at-risk mothers themselves, hit the local hair salons, churches, and other businesses to find neighbors in need.

“We were really well-staffed and we figured out how to market to the African-American community in a culturally responsible way.” — Kiko Malin, Alameda County Public Health Department

The unstable and transient lives of the women, who would sometimes move in and out of the nine zip codes, would not put an end to home visits from nurses like Tramiel. She would follow them like a godmother as long as they were still pregnant, or their child was still under a year old.

The county’s health professionals in all of these programs weren’t just working closely with the clients; they were often from the troubled zip codes themselves, and they were almost all black women.

“We were really well-staffed and we figured out how to market to the African-American community in a culturally responsible way,” said Kiko Malin, director of the Family Health Services Division at the Alameda County Public Health Department. “We had boots on the ground … Maybe we somehow had an impact.”

Malin uses the qualifier because she is genuinely unsure. She wrote in a follow-up email that it would be “myopic and incorrect” to assume the rate went down because of these efforts, sweeping as they were.

That’s because Alameda’s black infant mortality rate pushed back up to 8.9 per 1,000 births from 2011 through 2013. It continued to climb, and hit 11.6 in 2013 through 2015. The county’s most recent numbers, for 2014-2016, offer some hope, with a rate of 9.5 per 1,000.

Malin correctly points to two factors that caused this disheartening trend.

First, the black community in Alameda is more economically and socially marginalized than it was even a decade ago.

Health disparities, Malin said, are driven by “social inequalities and the resulting neighborhood conditions, such as poverty, homelessness, exposure to violence and trauma, and lack of access to healthy food.”

Second, in changes that are part of a five-year grant ending in 2019, the federal government has required Healthy Start programs to do more with the same amount of funding, and devote more resources to measuring outcomes, as opposed to providing assistance.

Before those changes, Alameda served about 400 families a year with a Healthy Start program focused on intervention. That has more than doubled to about 900 families a year, along with more staff hours devoted to gathering data on the health behaviors of clients.

The county used to hold Club Mom events twice a week. It now holds them twice a month. It no longer provides grocery store gift cards to peer health leaders.

Malin is confident that the new focus in Healthy Start on measuring outcomes will prove that mothers have changed their health behavior for the better. She is grateful for the funding.

“In the current political climate, who knows if that program will exist over the next decade?” she said of Healthy Start, a bipartisan effort begun in 1991 under George H. W. Bush. When the program began, Alameda’s black infant mortality rate was 17.7.

But like me, Malin can’t help but suffer from a little myopia at the sight of a black infant mortality rate that once achieved an all-time low of 7.6. An original goal of Healthy Start was to reduce infant mortality by 50 percent in communities with the highest rates.

Alameda County accomplished that, fleetingly.

“It seemed like we hit on something,” Malin said. “We’re doing our very best to maintain the integrity of the program. But it has shifted and has changed.”

This blog originally ran in the Annenberg Center for Health Journalism Blog. Click here to read it there.